Send Orders of Reprints at bspsaif@emirates.net.

ae
220 The Open Dentistry Journal, 2012, 6, (Suppl 1: M3) 220-225

Open Access

Current Status of Low Intensity Pulsed Ultrasound for Dental Purposes

Emanuel Braga Rego1,2,*, Takashi Takata1, Kazuo Tanne2 and Eiji Tanaka3

1
Department of Oral and Maxillofacial Pathobiology, Hiroshima University Graduate School of Biomedical Sciences,
Hiroshima, Japan
2
Department of Orthodontics and Craniofacial Developmental Biology, Hiroshima University Graduate School of Bio-
medical Sciences, Hiroshima, Japan
3
Department of Orthodontics and Dentofacial Orthopedics, Institute of Health Biosciences, The University of Tokushima
Graduate School, Tokushima, Japan

Abstract: Over the past few years, tissue engineering applied to the dental field has achieved relevant results. Tissue en-
gineering can be described by actions taken to improve biological functions. Several methods have been described to en-
hance cellular performance and low intensity pulsed ultrasound (LIPUS) has shown to play an important role in cell me-
tabolism.The present article provides an overview about the current status of LIPUS as a tissue engineering tool to be used
to enhance tooth and periodontal regeneration.

Keywords: Ultrasound, tissue engineering, periodontal healing.

INTRODUCTION mechanical stimuli [1]. Osteoclasts initiate bone resorption

Dental diseases affect millions of people worldwide.
Tooth decay, periodontal disease, dental pulp infection and
inflammatory root resorption can result in tooth loss and
seriously compromise human health and quality of life. In
this context, great efforts have been done to prevent oral
diseases and restore teeth and periodontal integrity. Over the
past few years, tissue engineering applied to the dental field
has achieved relevant results. Tissue engineering can be de-
scribed by actions taken to improve biological functions.
Several methods have been described to enhance cellular
performance and low intensity pulsed ultrasound (LIPUS)
has shown to play an important role in cell metabolism.
LIPUS stimulation is a classical therapeutic modality for
bone regeneration and its efficiency has been widely re-
ported over the years. Interestingly, recent studies have pro-
vided evidence that LIPUS plays an important role in the
metabolism of periodontal cells and tissues as well. The pre-
sent article provides an overview about the status of LIPUS
stimulation as tool to be used to enhance tooth and periodon-
tal regeneration.
1. LIPUS AND BIOLOGIC MECHANISMS
It is well known that mechanical stimulation plays a cru-
cial role in regulating bone physiology. During bone remod-
eling, bone resorption and new bone formation are induced
along the dominant local loading direction, suggesting that
local regulation of bone remodeling is mediated by
*Address correspondence to this author at the Department of Oral and Max-
illofacial Pathobiology, Hiroshima University Graduate School of Biomedi-
cal Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan;
Tel: +81-82-257-5686; Fax: +81-82-257-5687;
E-mail: emanuelbraga@hotmail.com
in response to determined signals that may relate to local
damage [2] and in response to a coupling signal, osteoblasts
are recruited to deposit bone matrix, which is later mineral-
ized [3]. The exact nature of the coupling signal is still un-
clear, but likely relates to local strain (deformation) levels.
Osteoclast and osteoblast activity could thus be related to
opposite strain modalities [4, 5].
It is well accepted that different patterns of mechanical
stimulation can induce distinct cell response. During ortho-
dontic tooth movement, for example, the networked reac-
tions that occur in and around periodontal ligament and al-
veolar bone cells change compressive and tensile stresses
into molecular events, resulting in bone resorption and for-
mation, respectively [6]. Based on these evidences, various
studies have been carried out to clarify the biological phe-
nomena underlying orthodontic tooth movement. It has been
shown experimentally that cells, located in the compression
area, respond differentially from those on the tension side in
terms of gene expression and enzymatic activity of bone
metabolism regulators [7]. Other types of mechanical stimu-
lation could thus modify cell metabolism, including ultra-
sound.
LIPUS (intensity ranging from 30 - 100 mW/cm2) is an
acoustic radiation that can be transmitted into the living tis-
sues as pressure waves resulting in biochemical events at the
cellular level [8]. LIPUS has been shown to stimulate bone
and cartilage cells in vitro, indicating that ultrasound exerts
direct anabolic effects such as production of growth factors
and other signaling molecules, osteogenic differentiation and
extra cellular matrix production [9]. The mechanisms in-
volved in LIPUS-stimulated tissue repair have not been elu-
cidated yet, however, it is recognized that the anabolic bio-

1874-2106/12 2012 Bentham Open

Current Status of Low Intensity Pulsed Ultrasound for Dental Purposes
physical effects caused by LIPUS are most likely to be
caused by mechanical stress and/or fluid micro-streaming
impacting on the cellular plasma membrane, focal adhesion
and cytoskeletal structures to trigger intracellular signal
transduction and subsequent gene transcription [10, 11].
2. LIPUS AND BONE REGENERATION
Mechanical stimulus to bone is of a great importance for
maintaining the bone mass and structural stability of the
skeleton. When bone is mechanically loaded, movement of
fluid within the spaces surrounding bone cells generates fluid
shear stress that stimulates osteoclasts and osteoblasts, re-
sulting in enhanced anabolic activity for bone remodeling
with appropriate bone resorption and the subsequent new
bone formation. The mechanisms such as mechanotransduc-
tion process, by which osteoclasts or osteoblasts convert the
external stimulation from fluid shear stress into biochemical
changes, remain unclear [12].
In vivo studies have demonstrated that therapeutic LIPUS
can promote bone repair and regeneration, accelerate bone
fracture healing, and enhance osteogenesis at the distraction
site [13-17]. It has also been shown in in vitro studies that
LIPUS stimulation can enhance expression of bone forma-
tion-related genes such as collagen type I and X, aggrecan,
transforming growth factor beta [18], runt related gene-2,
osteocalcin [19], insulin-like growth factor-I, bone sialopro-
tein [20] and alkaline phosphatase [21]. In addition, LIPUS
has been reported to promote protein synthesis and calcium
uptake in various osteoblastic cell lines [22]. Moreover,
LIPUS stimulation has been reported to enhance COX-2 gene
expression and subsequently enhance endogenous prostaglan-
din E2 (PGE2) synthesis in various osteoblastic cell lineages,
playing an important role in bone remodeling [23-25].
3. LIPUS AND PERIODONTAL LIGAMENT REGEN-
ERATION
Physiologically, the periodontal ligament is continuously
subjected to mechanical stress caused by occlusal forces.
Furthermore, remodeling of the ligament and alveolar bone
occurs in response to orthodontic forces. Taken together,
these clearly indicate that responses of the ligament to me-
chanical stress are involved in its cell proliferation and differ-
entiation. Periodontal ligament includes precursor cells of ce-
mentoblasts at the perivascular area in the middle portion and
shows greater differentiation toward the surface of the root
[26]. In a previous study, cyclic stretch stimulation mediated
periodontal ligament cells differentiation, thus regulating the
function of the periodontal ligament as a source of cemen-
toblasts and osteoblasts through the EGF/EGF-R system [27].
Regarding LIPUS effects, it has been reported to be ef-
fective in releasing fibroblast growth factors from a macro-
phage-like cell line [28]. We have reported previously that
LIPUS induced early cementoblastic differentiation of hu-
man immature cementoblasts from the periodontal ligament
by promoting the formation of substrate and increasing alka-
line phosphatase (ALP) activity, enabling the regeneration of
periodontal tissue destroyed by periodontal disease and the
acceleration of the repair of root resorption [29]. Mostafa et
al. (2009) demonstrated that ALP and OPN expressions were
also induced in human gingival fibroblasts treated with
The Open Dentistry Journal, 2012, Volume 6 221
LIPUS, confirming that after 3 weeks of 5min/day exposure
the osteogenic differentiation potential was enhanced [30].
4. LIPUS AND CEMENTUM REGENERATION
Cementum is a thin mineralized tissue covering the tooth
root surface and assists in anchoring teeth to surrounding
alveolar bone, maintaining the structural stability and
physiological function of the dentition [31]. Resorption of
the dental root surface can be a relevant adverse outcome of
orthodontic treatment. A certain degree of root resorption
occurs in most treatment cases, ranging from just a slight
apical resorption to a complete tooth root loss [32-36]. It is
well accepted that the cementum layer covering the root sur-
face plays a crucial role in preventing resorption during tooth
movement. In addition, the damaged areas are also repaired
in part by cementoblasts lining the root surface. Root resorp-
tion during orthodontic treatment is thus confirmed as a mul-
tifactorial event and several biological and mechanical fac-
tors have been identified to increase its susceptibility, how-
ever, the cause still remains unclear [37].
Cementoblasts share many characteristics with os-
teoblasts, including similar molecular properties and the abil-
ity to promote mineralization [38, 39]. Previous studies have
shown that, as in bone, cementum metabolism is also con-
trolled by mechanical stimulus. It has been reported that me-
chanical loading enhances the expression of phenotypic
makers such as OCN and BSP in cementoblast in vivo; how-
ever, the expression was just moderately stimulated com-
pared to osteoblasts [40]. Regarding ultrasound stimulation,
a pioneer study published by El-Bially et al. (2004) showed
that LIPUS prevented root resorption during experimental
tooth movement in humans [41]. Studies performed by our
group showed that LIPUS up-regulated the expression of
several genes related to mineral metabolism in mouse ce-
mentoblasts [42, 43]. We also reported in other article that
LIPUS simulation significantly up-regulated COX-2 mRNA
expression and enhanced PGE2 production inducing cemen-
toblastic differentiation and matrix mineralization through
EP2/EP4 prostaglandin receptors pathway [44].
Furthermore, we have also accessed the inhibitory effect
of a 21-day LIPUS application on root resorption using an
experimental model of tooth replantation involving luxation
and immediate replacement of maxillary first molars in rats
[45]. The results evidenced that the area of root resorption
lacunae was statistically decreased in LIPUS treated sample.
The imunne-expression of tumor necrosis factor alpha (TNF-
!) was not observed in LIPUS treated sample as was evident
as in the control sample. In addition, it was shown in vitro that
LIPUS may contribute to the reduction of the trauma-induced
inflammatory reaction through impairment of the TNF-
signaling pathway, suggesting that LIPUS shows potential as a
therapeutic tool to optimize the regenerative potential of
periodontal tissues on replanted teeth [45].
5. LIPUS AND GINGIVAL REGENERATION
Clinical trials applying LIPUS in implant dentistry have
reported accelerated soft-tissue healing as well as osseointe-
gration. In addition, it was suggested that the ultrasound-
treated wounds were at a more advanced stage in the repair
process [28]. Despite, details of the clinical effects of LIPUS
222 The Open Dentistry Journal, 2012, Volume 6
have not been well characterized, great efforts have been
done to clarify the cellular mechanisms underlying LIPUS-
induced tissue regeneration. Ikai et al. (2008) reported that a
daily LIPUS treatment protocol of 20 minutes for a period of
4 weeks has a benefic effect on gingival epithelium cells,
accelerating periodontal wound healing after flap surgery
[46]. In other study using gingival epithelial cells, Shiraishi
et al. (2011) reported that LIPUS accelerates soft-tissue heal-
ing by increasing the expression of connective tissue growth
factor (CCN2/CTGF), an important gene for wound healing
and angiogenesis in periodontal tissues [47].
6. LIPUS AND IMPLANT OSSEOINTEGRATION
The use of endosseous dental implants for replacing
missing teeth increased considerable over the last few years
and may be considered as the current most popular treatment
option for edentulous patients. This fact might be related to
the great effort on improving the osseointegration process.
Attention has been given to the surface and shape of the im-
plant [48, 49]. Other approaches focused on acid etching of
titanium surface [50], engineering of dental pulp cells on
various implant surfaces [51] and biomimetic implant coat-
ings containing bone morphogenetic protein-2 [52]. Other
methods targeted on enhancement of endogenous bone heal-
ing around biomaterials through different forms of biophysi-
cal stimulations such as pulsed electromagnetic fields [53] or
LIPUS [54].
A study of Tanzer et al. (1996) showed that LIPUS en-
hanced the rate and extent of bone growth into fully porous-
coated implants inserted into dog femora [55]. Hsu et al.
(2011) demonstrated in vivo that blood flow and mature type
I collagen fibers were more prevalent around titanium im-
plants, and bone formation was accelerated by ultrasound
stimulation. In addition, tissue culture of MG63 osteoblast-
like cells indicated that pulsed ultrasound effectively pro-
moted cell migration and new bone regeneration [56]. Ustun
et al. (2008) reported that the area, bone volume and bone-
implant contact ratio values, which are significant parame-
ters of histomorphometry assessments, have increased by
LIPUS stimulation in tibial bone, suggesting that LIPUS
application may accelerate and promote bone healing around
dental implants leading to a higher quality and faster os-
seointegration [57].
7. LIPUS AND PULP CELLS DIFFERENTIATION
AND TOOTH ERUPTION
Pulp tissue contains precursor cells which have the po-
tential to differentiate into odontoblasts. It is well understood
that after physiologic or pathologic stimulation pulp stem
cells may be recruited to proliferate and differentiate into
odontoblasts, which can produce dentin as a protection
mechanism [58]. It is also well documented that LIPUS has
the potential to induce bone and periodontal cells differentia-
tion [13-17, 28-30]. In this context, the effect of LIPUS on
pulp cells differentiation has risen as a subject of investigation.
A previous study showed that LIPUS (30 mW/cm2) promoted
odontoblast-like cells differentiation through stimulation of
vascular endothelial growth factor (VEGF) secretion [58]. It
has also been shown that ultrasound stimulation (0.5 W/cm2)
Braga Rego et al.
induced pulp stem cells to form reparative dentin formation in
vivo by optimizing gene transfer of growth/differentiation fac-
tor 11 plasmid DNA and subsequently up-regulation of dentin
sialoprotein gene expression [59].
An interesting study of El-Bialy et al. (2003) examined
the effect of therapeutic ultrasound on mandibular incisor
development and eruption in mature rabbits undergoing
mandibular osteodistraction. The results evidenced that ul-
trasound application combined with distraction enhanced
mandibular incisor growth and eruption. Histologic examina-
tion showed that the newly formed tissues at the distraction
site and at the cut ends of the incisor segments consisted of
osteodentin-like tissue and cementum [60].
8. LIPUS AND GENE DELIVERY
Periodontal disease or inflammatory root resorption is
relevant pathologic condition that can lead to tooth loss. In
this regard, several tissue-engineering techniques have been
proposed to restore periodontal integrity [61]. Administra-
tion of growth factors, for example, has proved to exert posi-
tive effect; however, some clinical limitations such as prote-
olytic degradation, rapid diffusion, and solubility of the de-
livery vehicle have been still problems to be solved [62]. In
order to optimize the results, gene transfer methods were
introduced; however, progress in experimental and clinical
periodontal gene therapy is limited by the immunogenicity
and cytotoxicity of viral vectors and low transfection effi-
ciency with regard to non-viral vectors [61, 63]. It has been
reported that therapeutic ultrasound associated to echo con-
trast agents such as nano/microbubbles can optimize gene
transfection in vitro and in vivo [63-67]. Recently, it has
been shown that therapeutic ultrasound also provides an ef-
fective gene delivery system for bone and periodontal regen-
eration [68-70]. Because ultrasound-mediated osteogenic
gene delivery has been just recently described, no consensus
about optimal ultrasound intensity and its exposure protocol
have been obtained yet. The use of LIPUS as a tool to opti-
mize gene transfection was described by Watanuki et al.
(2009). The study demonstrated that mouse calf muscles
injected with BMP-4 plasmids and transcutaneous electropo-
rated showed increased ectopic calcium and total collagen
content and bone area when exposed to LIPUS [71].
9. DISCUSSION
Among the causes of teeth loss, inflammatory root re-
sorption has received a great concern due to its unpredict-
ability, difficult control and lack of biological understanding.
the resorption of hard tissue in primary teeth is a normal
physiologic phenomenon that leads to their exfoliation and
ultimately the transition to permanent dentition. On the other
hand, the hard tissues of permanent teeth are not resorbed
under healthy conditions and the resorption is thus consid-
ered a pathologic process [72]. Different causes have been
attributed to the root resorption process including pressure,
inflammation, neoplastic process and systemic conditions
[73]; however, the biological phenomena underlying root
resorption are still not completely understood. Tooth root
resorption is regarded as a major problem encountered after
tooth replantation and orthodontic tooth movement. Eventu-
ally, the progression and severity of root resorption cannot
Current Status of Low Intensity Pulsed Ultrasound for Dental Purposes
be controlled and culminate with the complete tooth loss.
Approaches aiming to attenuate or inhibit root resorption and
restore periodontal integrity during the dental practice are
still the subject of debate and investigation. Some therapeu-
tic approaches have been proposed to inhibit root resorption
after tooth replantation and can induce periodontal regenera-
tion [74-77]. However, with respect to root resorption in-
duced by orthodontic tooth movement, less-accepted clinical
protocols have been established, probably due to the difficult
application and/or possibly side effects that medicamentous
treatment can generate. In this context, non-invasive modal-
ity such as LIPUS therapy has been given increased attention
and risen as promising therapeutic tool for the regeneration
of periodontium.
The effectiveness of LIPUS for bone regeneration is al-
ready universally accepted and some recent papers have pro-
vided evidence that it can exert benefic effects in other kinds
of tissues, including teeth. In addition, LIPUS presents low
toxicity, low immunogenicity, non-invasiveness, highly tar-
geted selectivity, and repeated applicability. However, the
diversity of techniques, application protocols and ultrasound
specifications found in the literature may cause confusion for
the clinician. Bains et al. (2008) have pointed out that ultra-
sound application in both diagnosis and periodontal therapy
seems to present promising results; however, long-term evi-
dence-based studies are required to use ultrasound in routine
periodontal practice [78].
10. CONCLUSIONS
Despite LIPUS therapy has been widely used in the fields
of orthopedic surgery and rehabilitation, its availability by
dental professionals is still incipient. The effects of LIPUS in
bony tissue seem to be well understood, but the literature has
still lacked for available information about its effects on
periodontal tissues. The present review brings out current
evidence that LIPUS has a positive effect on tooth and perio-
dontal cells metabolism, suggesting that LIPUS can be a
promising therapeutic tool for the regeneration of tooth
support tissues.
CONFLICT OF INTEREST
The authors confirm that this article content has no con-
flicts of interest.
ACKNOWLEDGEMENTS
Declared none.
REFERENCES
[1] Petrtyl M, Hert J, Fiala P. Spatial organization of the haversian
bone in man. J Biomech 1996; 29: 1619.
[2] Burr DB, Milgrom C, Fyhrie D, Forwood M, Nyska M, Finestone
A. In vivo measurement of human tibial strains during vigorous ac-
tivity. Bone 1996; 18: 40510.
[3] Everts V, Delaisse JM, Korper W, Jansen DC, Tigchelaar-Gutter
W, Beertsen W. The bone lining cell: Its role in cleaning How-
ships lacunae and initiating bone formation J Bone Miner Res
2002; 17: 77-90.
[4] Smit TH, Burger EH. Is BMU-coupling a strain-regulated phe-
nomenon? a finite element analysis. J Bone Miner Res 2000; 15:
301-7.
The Open Dentistry Journal, 2012, Volume 6 223
[5] Smit TH, Burger EH, Huyghe JM. A case for strain-induced fluid
flow as a regulator of BMU-coupling and osteonal alignment. J
Bone Miner Res 2002; 17: 2021-9.
[6] Masella RS, Meister M. Current concepts in the biology of ortho-
dontic tooth movement. Am J Orthod Dentofacial Orthop2006;
129: 458-68.
[7] Tan SD, Xie R, Klein-Nulend J, Van Rheden RE, Bronckers AL,
Kujipers-Jagtman AM, Van den Hoff JW, Maltha JC. Orthodontic
force stimulates eNOS and iNOS in rat osteocytes. J Dent Res
2009; 88: 255-60.
[8] Buckley MJ, Banes AJ, Levin LG, et al. Osteoblasts increase their
rate of division and align in response to cyclic mechanical tension
in vitro. Bone Miner 1998; 4: 225-36.
[9] Claes L, Willie B. The enhancement of bone regeneration by ultra-
sound. Prog Biophys Mol Biol 2007; 93: 384-98.
[10] Khan Y, Laurencin CT. Fracture repair with ultrasound: clinical
and cell-based evaluation. J Bone Joint Surg 2008; 90: 138-44.
[11] Romano CL, Romano D, Logoluso N. Low-intensity pulsed ultra-
sound for the treatment of bone delayed union or nonunion: a re-
view. Ultrasound Med Biol 2009; 35: 529-36.
[12] Young SR, Gerard-O'Riley R, Kim JB, Pavalko FM. Focal adhe-
sion kinase is important for fluid shear stress-induced mecha-
notransduction in osteoblasts. J Bone Miner Res 2009; 3: 411-24.
[13] Duarte LR. The stimulation of bone growth by ultrasound. Arch
Orthop Trauma Surg 1983; 101: 153-9.
[14] Dyson M. Therapeutic applications of ultrasound. In: Biological
effects of ultrasound. Nyborg WL, Ziskin MC, Eds. Churchill Liv-
ingstone, New York, NY 1985; pp. 121-33.
[15] El-Bialy TH, Royston TJ, Magin RL, Evans CA, ZakiAel M, Friz-
zell LA. The effect of pulsed ultrasound on mandibular distraction.
Ann Biomed Eng 2002; 30: 1251-61.
[16] Gebauer D, Correll J. Pulsed low-intensity ultrasound: a new sal-
vage procedure for delayed unions and nonunions after leg length-
ening in children. J Pediatr Orthop 2005;6:750-4.
[17] Erdogan O, Esen E, U stun Y, et al. Effects of low-intensity pulsed
ultrasound on healing of mandibular fractures: an experimental
study in rabbits. J Oral Maxillofac Surg 2006; 64: 180-8.
[18] Mukai S, Ito H, Nakagawa Y, Akiyama H, Miyamoto M, Naka-
mura T. Transforming growth factor-1 mediates the effects of
low-intensity pulsed ultrasound in chondrocytes. Ultrasound Med
Biol 2005; 31: 1713-21.
[19] Chen YJ, Wang CJ, Yang KD, et al. Pertussis toxin-sensitive Gi
protein and ERK dependent pathways mediate ultrasound promo-
tion of osteogenic transcription in human osteoblasts. FEBS Lett
2003; 554: 154-8.
[20] Naruse K, Mikuni-Takagaki Y, Azuma Y, et al. Anabolic response
of mouse bone-marrow-derived stromal cell clone ST2 cells to low-
intensity pulsed ultrasound. Biochem Biophys Res Commun 2000;
268: 216-20.
[21] Warden SJ, Favaloro JM, Bennell KL, et al. Low-intensity pulsed
ultrasound stimulates a bone forming response in UMR-106 cells.
Biochem Biophys Res Commun 2001; 286: 443-50.
[22] Naruse K, Miyauchi A, Itoman M, Mikuni-Takagaki Y. Distinct
anabolic response of osteoblasts to low-intensity pulsed ultrasound.
J Bone Miner Res 2003; 18: 360-9.
[23] Kokubu T, Matsui N, Fujioka H, Tsunoda M, Mizuno K. Low
intensity pulsed ultrasound exposure increases prostaglandin E2
production via the induction of cyclooxygenase-2 mRNA in mouse
osteoblasts. Biochem Biophys Res Commun 1999; 256: 284-7.
[24] Saito M, Fujii K, Tanaka T, Soshi S. Effect of low and high inten-
sity pulsed ultrasound on collagen post-translational modifications
in MC3T3-E1 osteoblasts. Calcif Tissue Int 2004; 75: 384-95.
[25] Tang CH, Yang RS, Huang TH, et al. Ultrasound stimulates cy-
clooxygenase-2 expression and increases bone formation through
integrin, focal adhesion kinase, phosphatidylinositol 3-kinase, and
Akt pathway in osteoblasts. Mol Pharmacol 2006; 69: 2047-57.
[26] Bosshardt DD, Degen T, Lsng NP. Sequence of protein expression
of bone sialoprotein and osteopontin at the developing interface be-
tween repair cementum and dentin in human deciduous teeth. Cell
Tissue Res 2005; 320: 399-407.
[27] Matsuda N, Yokoyama K, Takeshita, S, Watanabe M. Role of
epidermal growth factor and its receptor in mechanical stress-
induced differentiation of human periodontal ligament cells in vi-
tro. Arch Oral Biol 1998; 43: 987-97.
[28] Young SR, Dyson M. The effect of therapeutic ultrasound on angi-
ogenesis. Ultrasound Med Biol 1990; 16: 261-9.
224 The Open Dentistry Journal, 2012, Volume 6
[29] Inubushi T, Tanaka E, Rego EB, et al. Effects of ultrasound on the
proliferation and differentiation of cementoblast lineage cells. J Pe-
riodontol 2008; 79: 984-90.
[30] Mostafa NZ, Uluda H, Dederich DN, Doschak MR, El-Bialy TH.
Anabolic effects of low-intensity pulsed ultrasound on human gin-
gival fibroblasts. Arch Oral Biol 2009; 54: 743-8.
[31] Ten Cate AR. The periodontium: Oral histology, development,
structure and function. Mosby, St Louis, MO 2003; 276-9.
[32] Hollender L, Ronneman A, Thilander B. Root resorption, marginal
bone support and clinical crown length in orthodontically treated
patients. Eur J Orthod 1980; 2:197-205.
[33] Levander E, Malmgren O. Evaluation of the risk of root resorption
during orthodontic treatment: a study of upper incisors.Eur J Or-
thod 1988; 10: 30-8.
[34] Linge L, Linge BO. Patient characteristics and treatment variables
associated with apical root resorption during orthodontic treatment.
Am J Orthod Dentofacial Orthop 1991; 99: 35-43.
[35] Levander E, Malmgren O, Eliasson S. Evaluation of root resorption
in relation to two orthododntic treatment regimes. A clinical ex-
perimental study. Eur J Orthod 1994; 16: 223-8.
[36] Kurol J, Owman-Moll P, Lundgren D. Time related root resorption
after application of a controlled continuous orthodontic force. Am J
Orthod Dentofacial Orthop 1996; 110: 303-10.
[37] Rita FN, David EW, James LG. Tooth resorption. Quint Int 1999;
30: 9-25.
[38] Matias MA, Li H, Young WG, Bartold PM. Immunohistochemical
localization of extracellular matrix proteins in the periodontium
during cementogenesis in the rat molar. Arch Oral Biol 2003; 48:
709-16.
[39] Bosshardt DD. Are cementoblasts a subpopulation of osteoblasts or
a unique phenotype? J Dent Res 2005; 84: 390-406.
[40] Pavlin D, GluhakJ. Effect of mechanical loading on periodontal
cells. Crit Rev Oral Biol Med 2001; 12: 414-24.
[41] El-Bialy T, El-Shamy I, Graber TM. Repair of orthodontically
induced root resorption by ultrasound in humans. Am J Orthod
Dentofacial Orthop 2004; 126: 186-93.
[42] Dalla-Bona DA, Tanaka E, Oka H, et al. Effects of ultrasound on
cementoblast metabolism in vitro. Ultrasound Med Biol 2006; 32:
943-8.
[43] Dalla-Bona DA, Tanaka E, Inubushi T, et al. Cementoblast re-
sponse to low- and high-intensity ultrasound. Arch Oral Biol 2008;
53: 318-23.
[44] Rego EB, Inubushi T, Kawazoe A, et al. Ultrasound stimulation
induces PGE2 synthesis promoting cementoblastic differentiation
through EP2/EP4 receptor pathway. Ultrasound Med Biol 2010;
36: 907-15.
[45] Rego EB, Inubushi T, Miyauchi M, et al. Ultrasound stimulation
attenuates root resorption on rat replanted molars and impairs TNF-
signaling in vitro. J Periodont Res 2011; 46: 648-54.
[46] Ikai H, Tamura T, Watanabe T, et al.Low-intensity pulsed ultra-
sound accelerates periodontal wound healing after flap surgery. J
Periodont Res 2008; 43: 212-6.
[47] Shiraishi R, Masaki C, Toshinaga A, et al, Hosokawa R. The ef-
fects of low-intensity pulsed ultrasound exposure on gingival Cells.
J Periodontol 2011; 82: 1498-503.
[48] Brnemark PI, Zarb G, Albreksson T. Tissue-integrated prosthesis.
In: Brnemark PI, editor. Osseointegration in clinical dentistry.
Chicago, Il: Quintessence Publishing Co; 1985; pp. 11-76.
[49] Buser D, Schenk RK, Steinmann S, Fiorellini JP, Fox CH, Stich H.
Influence of surface characteristics on bone integration of titanium
implants. A histomorphometric study in miniature pigs. J Biomed
Mater Res 1991; 25: 889-902.
[50] Ericsson I, Johansson CB, Bystedt H, Norton MR. A histomor-
phometric evaluation of bone-to-implant contact on machine-
prepared and roughened titanium dental implants: a pilot study in
the dog. Clin Oral Implant Res 1994; 5: 202-6.
[51] Klokkevold PR, Johnson P, Dadgostari S, Caputo A, Davies JE,
Nishimura RD. Early endosseous integration enhanced by dual acid
etching of titanium: a torque removal study in the rabbit. Clin Oral
Implant Res 2001; 12: 350-7.
[52] Nakamura H, Saruwatari L, Aita H, Takeuchi K, Ogawa T. Mo-
lecular and biomechanical characterization of mineralized tissue by
dental pulp cells on titanium. J Dent Res 2005; 86: 515-20.
[53] Liu Y, DE Groot K, Hunkizer EB. BMP-2 liberated from
biomimetic implant coatings induces and sustains direct ossifica-
tion in an ectopic rat model. Bone 2005; 36: 745-57.
Braga Rego et al.
[54] Fini M, Giavaresi G, Setti S, Martini L, Torricelli P, Giardino R.
Current trends in the enhancement of biomaterial osteointegration:
Biophysical stimulation. Biomaterials 2004; 27: 681-90.
[55] Tanzer M, Harvey E, Kay A, Morton P, Bobyn JD. Effect of non-
invasive low intensity ultrasound on bone growth into porous-
coated implants. J Orthop Res 1996; 14: 901-6.
[56] Hsu SK, Huang WT, Liu BS, Li SM, Chen HT, Chang CJ. Effects
of near-field ultrasound stimulation on new bone formation and os-
seointegration of dental titanium implants in vitro and in
vivo.Ultrasound Med Biol 2011; 37: 403-16.
[57] Ustun Y, Erdogan O, Kurkcu M, Akova T, Damlar I. Effects of
low-intensity pulsed ultrasound on dental implant osseointegration:
a preliminary report. Eur J Dent 2008; 2: 254-62.
[58] Scheven BA, Man J, Millard JL, et al. VEGF and odontoblast-like
cells: stimulation by low frequency ultrasound. Arch Oral Biol
2009; 54: 185-91.
[59] Nakashima M, Tachibana K, Iohara K, Ito M, Ishikawa M, Aka-
mine A. Induction of reparative dentin formation by ultrasound-
mediated gene delivery of growth/differentiation factor 11. Hum
Gene Ther 2003; 14: 591-7.
[60] El-Bialy TH, el-MoneimZaki A, Evans CA. Effect of ultrasound on
rabbit mandibular incisor formation and eruption after mandibular
osteodistraction. Am J Orthod Dentofacial Orthop 2003; 124: 427-
34.
[61] Ramseier CA, Abramson ZR, Jin Q, Giannobile WV. Gene thera-
peutics for periodontal regenerative medicine. Dent Clin North Am
2006; 50: 245-63.
[62] Pradeep AR, Karthikeyan BV. Tissue engineering: prospect for
regenerating periodontal tissues. Indian J Dent Res 2003; 14: 224-
9.
[63] Nishida K, Doita M, Takada T, et al. Sustained transgene expres-
sion in intervertebral disc cells in vivo mediated by microbubble-
enhanced ultrasound gene therapy. Spine 2006; 31: 1415-9.
[64] Dijkmans PA, Juffermans LJ, Musters RJ, et al. Microbubbles and
ultrasound: from diagnosis to therapy. Eur J Echocardiogr 2004; 5:
245-56.
[65] BekeredjianR, Grayburn PA, Shohet RV. Use of ultrasound con-
trast agents for gene or drug delivery in cardiovascular medicine. J
Am Coll Cardiol 2005; 45: 329-35.
[66] Shimamura M, Sato N, Taniyama Y, et al. Development of effi-
cient plasmid DNA transfer into adult rat central nervous system
using microbubble-enhanced ultrasound. Gene Ther 2004; 11:
1532-9.
[67] Aoi A, Watanabe Y, Mori S, Takahashi M, Vassaux G, Kodama T.
Herpes simplex virus thymidine kinase-mediated suicide gene ther-
apy using nano/microbubbles and ultrasound. Ultrasound Med Biol
2008; 34: 425-34.
[68] Sheyn D, Kimelman-Bleich N, Pelled G, Zilberman Y, Gazit D,
Gazit Z. Ultrasound-based nonviral gene delivery induces bone
formation in vivo. Gene Ther 2008; 15: 257-66.
[69] Chen R, Chiba M, Mori S, Fukumoto M, Kodama T. Periodontal
gene transfer by ultrasound and nano/microbubbles. J Dent Res
2009; 88: 1008-13.
[70] Osawa K, Okubo Y, Nakao K, Koyama N, Bessho K. Osteoinduc-
tion by microbubble-enhanced transcutaneous sonoporation of hu-
man bone morphogenetic protein-2. J Gene Med 2009; 11: 633-41.
[71] Watanuki M, Kishimoto KN, Kotajima S, Iwabuchi S, Kokubun S.
Effect of low-intensity pulsed ultrasound on scaffold-free ectopic
bone formation in skeletal muscle. Ups J Med Sci 2009; 114: 242-
8.
[72] Gunraj MN. Dental root resorption. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1999; 88: 647-53.
[73] Ravindran S, Chaudhary M, Tumsare M, Patil S, Wadhwan V. A
Scanning electron microscopic study of the patterns of external root
resorption under different conditions. J Appl Oral Sci 2009; 17:
481-6.
[74] Loberg EL, Engstrom H. Thyroid administration to reduce root
resorption. Angle Orthod1994; 64: 395-9.
[75] Igarashi K, Adachi H, Mitani H, Shinoda H. Inhibitory effect of the
topical administration of a bisphosphonate (risedronate) on root re-
sorption incident to orthodontic tooth movement in rats. J Dent Res
1996; 75: 1644-9.
[76] Talic NF, Evans C, Zaki AM. Inhibition of orthodontically induced
root resorption with echistatin, an RGD-containing peptide. Am J
Orthod Dentofacial Orthop 2006; 129: 252-60.
Current Status of Low Intensity Pulsed Ultrasound for Dental Purposes The Open Dentistry Journal, 2012, Volume 6 225

[77] Fujishiro N, Anan H, Hamachi T, Maeda K. The role of macro- [78] Bains VK, Mohan R, Bains R. Application of ultrasound in perio-
phages in the periodontal regeneration using Emdogain gel. J Pe- dontics: Part II. J Indian Soc Periodontol 2008; 12: 55-61.
riodont Res 2008; 43: 143-55.

Received: July 05, 2012 Revised: August 10, 2012 Accepted: September 27, 2012

Braga Rego et al.; Licensee Bentham Open.

This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the
work is properly cited.